US embassy cable - 05AMMAN7237

UNCLAS SECTION 01 OF 03 AMMAN 007237 
 
SIPDIS 
 
STATE for S/GAC - Mamacos, Carson, Mikus 
STATE pass USAID for GH/MMiller 
HHS for OSOPHS - WSteiger 
 
SENSITIVE 
 
E.O. 12958: N/A 
TAGS: TBIO, EAGR, JO 
SUBJECT: (U) Jordan Response - Global Fund Parallel Review 
Process for Round Five Projects 
 
Ref: A) State 153140 B) 09/06/2005 Whittlesey-Mamacos email 
 
1.  (U) Summary: Text below is post's response to ref A 
request for an evaluation of Jordan's Round Five proposal on 
tuberculosis control to the Global Fund To Fight AIDS, TB 
and Malaria, emailed to S/GAC ref B. 
 
2.  (SBU) Begin text: 
Country: Jordan 
Region:  Middle East and North Africa 
Title:   Strengthening and Support National TB Program 
Jordan 
 
A.   Proposing Group: 
--------------------- 
National Country Coordinating Mechanism (CCM) 
 
Amount:   USD 2,782,864 
(Year 1 ($533,800) plus Year 2 ($539,064) = $1,072,864) 
 
B. Overall comments and recommendations for U.S. delegation 
position: 
--------------------------------------------- ----------- 
 
The aim of Jordan's TB program is to reduce TB morbidity and 
mortality. The main objectives are: 
-- To improve TB care and treatment among vulnerable groups, 
specifically the poor, refugees, immigrant, and mobile 
populations. 
-- Establish and upgrade nine service delivery points among 
refugees, and poor areas and two mobile care points of 
delivery. 
-- To implement DOTS plus (Directly Observed Treatment, 
Short course) through a global initiative the Green Light 
Committee (GLC) in the Amman reference hospital and one 
clinic for ambulatory care and drug-resistant surveillance 
(DRS). 
-- To strengthen TB managerial capacity through partnership 
development, lab strengthening, computerized monitoring and 
evaluation (M&E) and the Practical Approach on Lung Health 
(PAL) strategy 
 
Jordan's TB program (NTP) is vertical in nature, is managed 
in Amman, and is the sole provider of total TB care 
throughout the country.  The overall goal of the program is 
to reduce morbidity and mortality due to TB and to reduce 
multi-drug resistant (MDR) TB in Jordan. 
 
The NTP operates at three levels: 
-- Central Level: Ministry of Health's (MOH) Chest Disease 
Directorate is responsible for the national TB program and 
coordinates and supervises all TB control activities.  It 
also supplies the chest clinics with requisite drugs, 
supplies, reagents, etc. 
-- Regional Level: 12 TB diagnostic centers throughout the 
country. 
-- District Level: the TB program is partially integrated 
with the Primary Health Centers/Clinics (PHC) to adopt the 
DOTS strategy. 
 
Areas of Success 
---------------- 
The Executive Summary states (Section 2.1.4): The NTP has 
been in operation since early 1973 and has achieved a good 
deal of success.  Examples of activities that have been 
implemented which have resulted in achieving success in 
different components are: 
-- The NTP/MOH provides free anti-TB drugs to all diagnosed 
patients (Jordanians and foreigners) and free screening of 
all contacts. 
-- The NTP achieved more than an 80% success rate among 
newly discovered cases, but this rate is lower than 30% 
among treatment and multi-drug resistant (MDR) cases.  Low 
success with MDR indicates the need to develop a strategy to 
treat MDR cases. 
 
Areas for improvement 
--------------------- 
While the NTP provides a few types of training courses, it 
believes it important to increase the administrative, 
management and technical skills of the central and 
intermediate program staff. 
 
Surveillance through central and district levels needs to be 
improved and upgraded by introducing appropriate Management 
Information Systems (MIS) and other data systems (electronic 
registration and website). 
 
The NTP needs to strengthen and intensify public awareness 
of TB through a variety of approaches and ensuring health 
education for the patient and adherence to treatment. 
 
The NTP wishes to develop national and international 
institutional collaboration to conduct operations research. 
Mobile units are needed to survey vulnerable groups and hard 
to reach populations. 
 
The central and provincial laboratories need to be upgraded 
and staffed with highly qualified technical personnel and 
modern equipment. 
 
A primary interest of the NTP is continuing medical 
education (CME) for its physicians and researchers. 
Constraints: 
------------ 
With the above as background, it should be noted that the 
leadership and staff of the NTP are enthusiastic, committed, 
and have a strong work ethic.  However, the TB Department in 
Amman that manages the vertical NTP for the entire country 
is experiencing the following constraints: 
-- Heavy workload; i.e., 1,800 cases per day of foreigners 
alone (e.g., construction workers, etc.) 
-- Lack of modern equipment to handle the increasing 
workload 
-- No computerized MIS system, data base, or trained data 
entry staff (currently rely on manual log book) 
-- Less than optimal patient flow through the facility 
-- Less than optimal patient confidentiality and privacy 
-- Less than optimal case detection 
-- Linkages and collaboration with other public health 
sectors (i.e., HIV/AIDS) needs to be expanded/strengthened 
to achieve NTP objectives and provide better services 
 
Recommendations: 
---------------- 
To address these constraints and strengthen and expand the 
NTP, post recommends that the TB proposal be approved for an 
initial two year period on condition that the following 
issues are addressed over that timeframe: 
-- Targeted technical assistance be included in the proposal 
or provided by the Government of Jordan (GOJ) or, in the 
short term, by donors (NOTE: USAID/Jordan has no funds for 
such technical assistance except as noted in footnote ** 
below.) 
-- Develop the 10-year strategic plan for TB control (pp. 36- 
79 and 55-79 of the proposal), with technical assistance, if 
necessary.  It would be ideal if this strategic plan were 
developed in the same way that Jordan's HIV/AIDS strategy 
was developed. (See footnotes * and **.) 
-- A robust, results-oriented Monitoring and Evaluation Plan 
(M&E) be developed similar to that developed for HIV/AIDS. 
Without an improved MIS/database, reliable and credible 
reporting on indicators will not be possible.) 
-- Develop a comprehensive plan for reaching vulnerable 
groups 
-- Develop a comprehensive list of sub-recipients and 
network for TB information and services 
 
C. Comments on Technical Review Panel (TRP) review 
(especially disagreements/omissions) 
--------------------------------------------- ------------- 
 
-- Post disagrees with the TRP statement that the Amman TB 
facility is "a health center of excellence" since it needs a 
great deal of upgrading and modernization to make it a true 
center of excellence. 
 
-- Regarding the strengths outlined by the TRP: 
(1) Bullet 1: post agrees that the proposal is relatively 
comprehensive and includes rational objectives and 
activities that address essential components of the TB 
control program (i.e., migrants, DOTS plus, laboratory 
strengthening, etc.). 
(2) Bullet 2:  there is a very high level of political 
commitment for TB control by the GOJ and the MOH, including 
financial support from the government; 
(3) Bullet 3: there is partnership with NGOs and UN Relief 
and Works Agency (UNRWA).  But as stated above, the network 
of organizations capable of TB work should be expanded; and 
(4) Bullet 4: post disagrees with the TRP's assessment that 
this is a fully "successful TB program."  While it has 
achieved a great deal since its inception, it still has a 
long way to go to be a truly successful TB program, 
especially in light of the programmatic constraints noted 
above. 
-- Regarding the weaknesses outlined by the TRP: 
(1) Bullet 1: post believes, is addressed above; 
(2) Bullet 2: additional approaches on mortality and/or 
disease prevalence surveys could be addressed in Jordan by 
exploring existing mechanisms or surveillance systems; 
(3) Bullet 3: post agrees that including the HIV prevalence 
survey among TB cases within the HIV/AIDS M&E matrix makes 
good sense. 
 
-- Costs: Unfortunately, post could not open the budget 
attachment related to the costs cited in the TRP document. 
This issue was discussed with a local colleague familiar 
with the budgeting process who explained that the cost 
examples outlined in the TRP review are reasonable and based 
on WHO's current practices and costs in country.  However, 
these costs do not include technical assistance which, when 
added, would increase these types of costs dramatically. 
 
D. Other public health or scientific considerations 
(appropriateness, coverage, capacity issues, feasibility, 
monitoring): 
--------------------------------------------- ----------- 
Post believes that this has been addressed above. 
 
E.  Coordination with other partners (including potential 
duplication): 
--------------------------------------------- ----------- 
Stronger coordination with the HIV/AIDS program in 
particular would benefit the TB program.  Similarly, further 
collaboration with other local partner organizations capable 
of TB work should be explored under the 10-year Strategic 
Plan for TB Control. 
 
F. Political considerations: 
---------------------------- 
Jordan accords a high level of political commitment to TB 
control including government financial support and 
additional staff required to implement the proposal. 
 
G. Additional comments: 
----------------------- 
N/A 
 
H.  Embassy point of contact: 
----------------------------- 
David L. Piet, Team Leader, Population and Family Health, 
USAID/Jordan 
Email:  dpiet@usaid.gov   Phone: 962-6-590-6622 
 
Footnotes : 
 
* The TB section of the proposal was authored by senior 
officials of the TB Department, NTP/MOH, with assistance 
from the WHO's Eastern Mediterranean Region (WHO/EMRO). 
Thus, the TB proposal is rather general and lacks specifics 
that should be addressed during the first two years.  The 
HIV/AIDS section of the proposal, by contrast, was 
strategically and comprehensively developed with the 
assistance of an international expert working in close 
collaboration the National AIDS Program (NAP), the CCM, and 
a wide array of public-private-NGO-donor experts. 
 
** While USAID/Jordan does not have the funding resources 
necessary to provide technical assistance to the NTP, 
USAID's Family Health International (FHI/Jordan) is willing 
and able to provide limited technical assistance to the NTP 
to strengthen the linkage between the NTP and the HIV/AIDS 
programs.  However, the NTP will need specialized technical 
assistance to increase its effectiveness. 
 
HALE